Provider Demographics
NPI:1831181270
Name:LUCAS, IRENE DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:DIANE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 N MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1117
Mailing Address - Country:US
Mailing Address - Phone:570-474-6562
Mailing Address - Fax:570-474-0796
Practice Address - Street 1:62 N MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1117
Practice Address - Country:US
Practice Address - Phone:570-474-6562
Practice Address - Fax:570-474-0796
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0339709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010752110001Medicaid
PA189886Medicare ID - Type Unspecified
B40956Medicare UPIN